Original Contributions| Volume 57, ISSUE 4, P461-468, October 2019

A Comparison of the Efficacy of Enema Solutions in Pediatric Emergency Department Patients



      Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection.


      Our aim was to assess and compare the efficacy of the various enema solutions used in a pediatric ED, including the “pink lady,” a previously unreported compounded combination of docusate, magnesium citrate, mineral oil, and sodium phosphate.


      We identified all children who received any enema over a 5-year period in an urban, quaternary care pediatric ED for inclusion in the study via electronic record review. Physician investigators retrospectively reviewed routine visit documentation to confirm the type and dosage of enema and assess comorbidities, indications, efficacy, and side effects. Subjective descriptions of output were classified as none, small, medium, or large by reviewer consensus.


      There were 768 records included. Median age was 6.2 years (interquartile range 3.3–10.3 years). Solutions used were sodium phosphate (n = 396), pink lady (n = 198), soap suds (n = 160), and other (n = 14). There was no significant difference in output by solution type (p = 0.88). Volume delivered was highest for pink lady, with no significant association between volume delivered and output (p = 0.48). Four percent of patients had side effects. Soap suds had a significantly higher rate of side effects (10.6%; p = 0.0003), primarily abdominal pain.


      There was no significant difference in reported stool output produced by sodium phosphate, soap suds, and pink lady enemas in children treated in an ED. Further study via randomized controlled trials would be beneficial in guiding selection of enema solution.


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        • Nutter A.
        • Meckler G.
        • Truong M.
        • Doan Q.
        Constipation and paediatric emergency department utilization.
        Paediatr Child Health. 2017; 22: 139-142
        • Caperell K.
        • Pitetti R.
        • Cross K.P.
        Race and acute abdominal pain in a pediatric emergency department.
        Pediatrics. 2013; 131: 1098-1106
        • Miller M.K.
        • Dowd M.D.
        • Fraker M.
        Emergency department management and short-term outcome of children with constipation.
        Pediatr Emerg Care. 2007; 23: 1-4
        • Mugie S.M.
        • Di Lorenzo C.
        • Benninga M.A.
        Constipation in childhood.
        Nat Rev Gastroenterol Hepatol. 2011; 8: 502-511
        • Miller M.K.
        • Dowd M.D.
        • Friesen C.A.
        • Walsh-Kelly C.M.
        A randomized trial of enema versus polyethylene glycol 3350 for fecal disimpaction in children presenting to an emergency department.
        Pediatr Emerg Care. 2012; 28: 115-119
        • Freedman S.B.
        • Thull-Freedman J.
        • Rumantir M.
        • Eltorki M.
        • Schuh S.
        Pediatric constipation in the emergency department: evaluation, treatment, and outcomes.
        J Pediatr Gastroenterol Nutr. 2014; 59: 327-333
        • Chumpitazi C.E.
        • Henkel E.B.
        • Valdez K.L.
        • Chumpitazi B.P.
        Soap suds enemas are efficacious and safe for treating fecal impaction in children with abdominal pain.
        J Pediatr Gastroenterol Nutr. 2016; 63: 15-18
        • Rajindrajith S.
        • Devanarayana N.M.
        Constipation in children: novel insight into epidemiology, pathophysiology and management.
        J Neurogastroenterol Motil. 2011; 17: 35-47
        • Hansen S.E.
        • Whitehill J.L.
        • Goto C.S.
        • Quintero C.A.
        • Darling B.E.
        • Davis J.
        Safety and efficacy of milk and molasses enemas compared with sodium phosphate enemas for the treatment of constipation in a pediatric emergency department.
        Pediatr Emerg Care. 2011; 27: 1118-1120
        • Wallaker K.
        • Fortuna E.
        • Bradin S.
        • Macy M.
        • Hassan M.
        • Stanley R.
        Milk and molasses enemas: clearing things up.
        J Emerg Nurs. 2014; 40: 546-551
        • Vilke G.M.
        • DeMers G.
        • Patel N.
        • Castillo E.M.
        Safety and efficacy of milk and molasses enemas in the emergency department.
        J Emerg Med. 2015; 48: 667-670
        • Bekkali N.L.
        • van den Berg M.M.
        • Dijkgraaf M.G.
        • et al.
        Rectal fecal impaction treatment in childhood constipation: enemas versus high doses oral PEG.
        Pediatrics. 2009; 124: e1108-e1115
        • Mendoza J.
        • Legido J.
        • Rubio S.
        • Gisbert J.P.
        Systematic review: the adverse effects of sodium phosphate enema.
        Aliment Pharmacol Ther. 2007; 26: 9-20
        • Biebl A.
        • Grillenberger A.
        • Schmitt K.
        Enema-induced severe hyperphosphatemia in children.
        Eur J Pediatr. 2009; 168: 111-112
        • Marraffa J.M.
        • Hui A.
        • Stork C.M.
        Severe hyperphosphatemia and hypocalcemia following the rectal administration of a phosphate-containing Fleet pediatric enema.
        Pediatr Emerg Care. 2004; 20: 453-456
        • Davis R.F.
        • Eichner J.M.
        • Bleyer W.A.
        • Okamoto G.
        Hypocalcemia, hyperphosphatemia, and dehydration following a single hypertonic phosphate enema.
        J Pediatr. 1977; 90: 484-485
        • Craig J.C.
        • Hodson E.M.
        • Martin H.C.
        Phosphate enema poisoning in children.
        Med J Aust. 1994; 160: 347-351
        • Walker M.
        • Warner B.W.
        • Brilli R.J.
        • Jacobs B.R.
        Cardiopulmonary compromise associated with milk and molasses enema use in children.
        J Pediatr Gastroenterol Nutr. 2003; 36: 144-148
        • Harish K.
        • Tony J.
        • Sunilkumar R.
        • Thomas V.
        Severe colitis induced by soap enemas.
        Indian J Gastroenterol. 2006; 25: 99-100
        • Orchard J.L.
        • Lawson R.
        Severe colitis induced by soap enemas.
        South Med J. 1986; 79: 1459-1460
        • Smith D.
        Severe anaphylactic reaction after a soap enema.
        Br Med J. 1967; 4: 215
        • Hyman C.
        The mineral oil-soapsuds enema: an old mixture with new uses.
        Sinai Hosp J (Balt). 1954; 3: 36-40
        • Flentie E.H.
        • Cherkin A.
        Electrolyte effects of the sodium phosphate enema.
        Dis Colon Rectum. 1958; 1: 295-299
        • Sood M.R.
        Chronic functional constipation and fecal incontinence in infants and children: treatment. UpToDate.
        (Available at:)
        • Russell K.W.
        • Barnhart D.C.
        • Zobell S.
        • Scaife E.R.
        • Rollins M.D.
        Effectiveness of an organized bowel management program in the management of severe chronic constipation in children.
        J Pediatr Surg. 2015; 50: 444-447
        • Ibrahim T.
        • Li Wei C.
        • Bautista D.
        • Sriram B.
        • Xiangzhen F.L.
        • Rajadurai V.S.
        Saline enemas versus glycerin suppositories to promote enteral feeding in premature infants: a pilot randomized controlled trial.
        Neonatology. 2017; 112: 347-353
        • Youssef N.N.
        • Barksdale Jr., E.
        • Griffiths J.M.
        • Flores A.F.
        • Di Lorenzo C.
        Management of intractable constipation with antegrade enemas in neurologically intact children.
        J Pediatr Gastroenterol Nutr. 2002; 34: 402-405
        • Hyde S.J.
        • Coulthard M.G.
        • Jaffray B.
        • Vallely M.E.
        • Harding S.M.
        Using saline solutions for ACE washouts.
        Arch Dis Child. 2008; 93: 149-150
        • Moylan S.
        • Armstrong J.
        • Diaz-Saldano D.
        • Saker M.
        • Yerkes E.B.
        • Lindgren B.W.
        Are abdominal x-rays a reliable way to assess for constipation?.
        J Urol. 2010; 184: 1692-1698
        • Berger M.Y.
        • Tabbers M.M.
        • Kurver M.J.
        • Boluyt N.
        • Benninga M.A.
        Value of abdominal radiography, colonic transit time, and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children: a systematic review.
        J Pediatr. 2012; 161 (50.e1–50.e2): 44